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London Intermediate Minor Oral Surgery Referral Form 22.06.18PATIENT DETAILSPatient’s Title and Name: Gender:Date of Birth:Patient’s Address: Postcode Patient’s email address:Contact Number: (mobile preferred for SMS messaging):NHS Number (if known):REFERRER DETAILSReferrer’s Name:Practice Postcode:Interpreter required? Language?YES / NOPractice Name and Address:Practice phone number: GDC Number:Patient’s GP Name and Address including postcode:Practice E=mail address: Telephone: If urgent care, please state why:972515126364 00 Please tick if a wheelchair user 2159865126365 00 1156335-3196590 London Region00 London Region918210-3644265 00 Please confirm the patient consents to thisreferral and understands the reason for it: REASON FOR REFERRAL INTO IMOS SERVICEPlease tick one box and complete the Justification for Referral section below.Surgical removal of uncomplicated third molars involving bone removalSurgical removal of buried roots and fractured or residual root fragmentsManagement and surgical removal of uncomplicated ectopic teeth (including supernumerary teeth)Management and surgical exposure of teeth to include bonding of orthodontic bracket or chain.Failed extractionOther, please specify:Minor soft tissue surgery to remove apparent non-suspicious lesions with appropriate histopathological assessment and diagnosis, e.g. fibroepithelial polyp and mucocele.REASON FOR REFERRAL INTO SECONDARY CAREPlease tick one box and complete the Justification for Referral section below.Extraction of erupted tooth/teeth/roots in medically compromised patients who cannot be managed in IMOS primary careExtraction of impacted tooth/teeth in medically compromised patients who cannot be managed in IMOS primary careOrthodontic extractions/Supernumerary/Expose+/- bond in medically compromised patients who cannot be managed in IMOS primary careMajor facial and jaw trauma including fractures and soft tissue injuriesSoft tissue swellings of the mouth, jaws, neck, thyroid and salivary glandsComplex hard tissue swellings of the mouth, jaws, neck, thyroid and salivary glandsComplex oral and mucosal ulceration; red and white patches of the mucosaSalivary and gland disorders (lumps, chronic/obstructive salivary diseases and complex mucoceles (ranula)Primary dentofacial deformity/orthognathic surgeryComplex dental cysts and cysts of the jawTMJ – less than 2cm inter-incisal spaceOther, please specify:Failed extractionIdiopathic facial pain should be referred to the local facial pain service.Implants, bone grafting and apical surgery should be referred to restorative dentistry.Justification for Referral Further information, including why specialist care is required and all previous treatment for the condition. For third molars, explain how NICE guidelines are met. For TMJ, provide details of interincisal opening and date and review for splint.CLINICALLY DIAGNOSTIC, RELEVANT RADIOGRAPHS MUST BE ATTACHED FOR ALL EXTRACTIONS PLEASE INDICATE TOOTH REQUIRING TREATMENTPERMANENT DENTITION555879010414080085217795113665700748742601047756006418719010668040044531360104775500531642051136651001349885011303020023846195113665300374993510604570074152901054108008110109011049060061445260108585500517868901123954004213042511112530032474595113030200228155901136651001556387014668580085217160139065700748710851365256006418747114506840041460500140335500517856201384304004212788514795530032815590138430100111004551358906006754380140335700741656013779580084545965-317550053843655-698530033503295-317520023162935-508010012476434-32242002PRIMARY DENTITION452882094615E00E144462597155E00E178879592710D00D418465094615D00D384492596520C00C350012093345B00B315722094615A00A212852088900C00C247332595885B00B281749590805A00A4541520126365E00E4186555133350D00D3846195120015C00C3496310127000B00B3161665133985A00A2814320126365A00A1444625133985E00E1791335129540D00D2129790122555C00C2465705123825B00BRELEVANT MEDICAL HISTORY FORMDO NOT LEAVE ANY SECTION BLANK, FOR YES X FOR NOPatient is healthy with no known medical conditionsHIV / TB / CJDHeart problemsOsteoporosis or bone / joint problemsHigh blood pressureSkin conditionsAsthma / COPD / Chest problemsMental health conditionsCVD/Epilepsy / Neurological conditions / Parkinson’s DiseaseBleeding disorders / Coagulopathy / Sickle Cell diseaseDiabetes / Thyroid / Endocrine conditionsDrug dependencyGastric diseaseAlcohol dependencyLiver disease / HepatitisAllergiesKidney diseaseCancerHas the patient had, or are they currently receiving:ChemotherapyRadiotherapy to the head and / or neckBisphosphonates (oral / IV), if so please state type and duration in medications box belowAnti-coagulant / anti-platelet medication, if so please state the type and duration in medications box belowDoes the patient have a:Learning disabilityVisual impairmentHearing impairmentMobility impairmentPlease give further details of medical conditions:Please give details of ALL medications (if applicable):Any suspected malignancy of the mouth/jaws must be referred via the two week wait patient referral pathway.I have read and understood the guidance notes for referrals of this type:Signed: __________________________________________ Date: _______________Further guidance for referrals to Oral Surgery Details of complexity levels can be found in Guide for Commissioning Oral Surgery and Oral Medicine () Level 1 complexity Procedures/conditions to be performed or managed by a clinician commensurate with a level of competence as defined by the Curriculum for Dental Foundation Training or its equivalent. This is the minimum that a commissioner would expect to be delivered in a primary care contract.Level 2 complexityProcedures/conditions to be performed or managed by a clinician with enhanced skills, and experience who may or may not be on a specialist list. This care may require additional equipment or environment standards but can usually be provided in a primary care setting. Level 3a complexityProcedures/conditions to be performed or managed by a clinician recognised as a specialist at the GDC defined criteria and on a specialist list; OR by a consultant. Level 3b complexityProcedures/conditions to be performed or managed by a clinician recognised as a consultant in the relevant specialty, who has received additional training which enables them to deliver more complex care, lead MDTs, MCNs and deliver specialist training. The consultant team may include trainees and SAS grades. Oral Surgery to also be delivered by Consultants in Oral & Maxillofacial Surgery who have the necessary competencies. LEVEL 1 procedures/conditionsExtraction of erupted tooth/teeth including erupted uncomplicated third molarsEffective management, including assessment for referral unerupted, impacted, ectopic and supernumerary teethExtraction as appropriate of buried roots (whether fractured during extraction or retained root fragments),Understanding and assistance in the investigation, diagnosis and effective management of oral mucosal diseaseEarly referral of patients (using 2-week pathway) with possible pre-malignant or malignant lesionsManagement of dental trauma including re-implantation of avulsed tooth/teethManagement of haemorrhage following tooth/teeth extractionDiagnosis and treatment of localised odontogenic infections and post-operative surgical complications with the appropriate therapeutic agentsDiagnosis and referral patients with major odontogenic infections with the appropriate degree of urgency. Recognition of disorders in patients with craniofacial pain including initial management of temporomandibular disorders and identification of those patients that require specialised managementLEVEL 2 procedures/conditions Surgical removal of uncomplicated third molars involving bone removalSurgical removal of buried roots and fractured or residual root fragmentsManagement and surgical removal of uncomplicated ectopic teeth (including supernumerary teeth)Management and surgical exposure of teeth to include bonding of orthodontic bracket or chainSurgical endodontics Minor soft tissue surgery to remove apparent non-suspicious lesions with appropriate histopathological assessment and diagnosis.eg: Fibroepithelial polyp & mucocele Failed extraction (attempted extraction not completed) LEVEL 3 procedure/conditions Procedures involving soft/hard tissues where there is an increased risk of complications (such as nerve damage, displacement of fragments into the maxillary antrum and fracture of the mandible)Management and/or treatment of salivary gland diseaseSurgical removal of tooth/teeth/root(s) that may involve access into the maxillary antrum Management of temporomandibular disorders and craniofacial pain that have not responded to initial therapyTreatment of cystsManagement of suspicious/non-suspicious oral lesionsThe placement of dental implants (that are eligible under the NHS) requiring complicated additional procedures such as bone grafting, sinus lifts etc. Treatment of complex dentoalveolar injuriesManagement of spreading infections and incision of abscesses (or abscess) requiring an extra-oral approach to drainDepending on the complexity of the procedure, consultant-led care may be required to manage any of the above and, in addition, is required for the procedures listed below. These procedures will be delivered within a team (which may include specialist trainees, specialists and SAS grades) who have appropriate ability and facilities to provide high quality care for patients:management of jaw and facial fracturesmanagement of congenital and acquired jaw anomaliesadvanced oral implantology and bone augmentationdiagnosis and treatment of anomalies and diseases of the TMJdiagnosis and treatment of salivary gland diseases. THIRD MOLARSStrict adherence to the NICE guidelines will be observed.For clarity these include:Unrestorable cariesRestorable caries in the adjacent tooth that necessitates extraction of third molar to restore the cariesNon-treatable pulpal/periapical pathologyCellulitisAbscessOsteomyelitisInternal/external resorption of the tooth or adjacent toothFracture of toothDisease of follicle (cyst/tumour)Documented pericoronitis on more than one occasion requiring medical or surgical treatmentREASONS FOR REFERRALS TO BE RETURNED TO GDPForm is not typed or legibleNo performer detailsNo practice detailsNo reason given for need for specialist careNo GP detailsNo reason given why surgical extraction likely No medical history or insufficient detailsRadiograph of insufficient quality to be clinically diagnostic ................
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